Antenatal Appendicular Perforation K.L

Medical Journal 1001-1003 Postgraduate (1987) 63, Postgrad Med J: first published as 10.1136/pgmj.63.745.1001 on 1 November 1987. Downloaded from Antenatal appendicular perforation K.L. Narasimharao, S.K. Mitra and I.C. Pathak Department ofPaediatric Surgery, Postgraduate Institute ofMedical Education and Research, Chandigarh 160 012, India

Summary: Antenatal appendicular perforation leading to localized meconium peritonitis and intestinal obstruction is reported in a premature neonate. The baby was successfully treated by a limited ileocaecal resection.

Introduction Appendicitis is rare in the neonatal period.'-4 We limited ileocaecal resection was performed with ileo- report a successfully treated case of localized mecon- ascending colon anastomosis (Figure 2). ium peritonitis secondary to an antenatal appen- Histological sections from the terminal ileum and dicular perforation in a premature low birth weight caecum showed normal mucosa and ganglion cells. This is believed to be the second case of Sections from the appendix showed ulceration of the baby. reported Protected by copyright. meconium peritonitis due to in utero appendicular mucosa with increased lymphomononuclear cells in perforation.

Case report A 12 day old female neonate, born at 32 weeks gestation, to a third gravida mother by normal vaginal delivery was admitted with constipation and abdominal distension since birth. The antenatal his- tory was unremarkable except for prematurity. She had passed a small amount of meconium at 8 hours after birth. Later, she was able to pass only a few hard and dry pellets occasionally with rectal suppositories. The baby weighed 1400g and the abdomen was http://pmj.bmj.com/ uniformly distended with visible intestinal peristalsis. A hard, nodular and fixed intra-abdominal mass 3 x 3cm was palpable in the right iliac fossa. The anorectum was normal. The laboratory data were unremarkable. Plain radiographs of the abdomen showed the mass in the right iliac fossa to be calcified and distension of small bowel (Figure 1). A gaseous on September 23, 2021 by guest. gastroconray study revealed a narrow calibre colon. Although repeated warm saline rectal washes relieved the obstruction temporarily, acute intestinal obstruction developed again, a week later. At laparotomy, the calcified mass was seen encasing the distal half of the appendix and the terminal ileum. There were dense adhesions around this mass. Lysis of adhesions and Correspondence: K.L. Narasimharao, M.B., M.S., M.Ch., M.N.A.M.S. cification in the right iliac fossa and gaseous distension of Accepted: 10 April 1987 small bowel. © The Fellowship of Postgraduate Medicine, 1987 1002 CLINICAL REPORTS Postgrad Med J: first published as 10.1136/pgmj.63.745.1001 on 1 November 1987. Downloaded from

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Figure 2 Resected specimen showing the distal half of the appendix and terminal ileum covered by a mass of calcified meconium. The ileum proximal to this area is dilated. Protected by copyright. lamina propria, oedema and hyperaemia in the sub- occurs in the fetus, the lumen of appendix is larger at mucosa, prominent lymphoid follicles, organizing its junction with the caecum than at its tip.8 Perfora- serositis with perforation, and calcification. The post- tion of the appendix in neonates may occur secondary operative recovery was uneventful. A rectal biopsy to obstructive lesions like Hirschsprung's disease, showed normal ganglion cells. The child was dischar- colonic atresia, imperforate anus or ischaemic lesions ged home with normal bowel habits. like necrotizing enterocolitis.9 Idiopathic perforation of bowel in the absence of intestinal obstruction may be due to aplasia of the muscularis mucosa, primary Discussion vascular insufficiency or a localized vascular accident.9'0 Acute appendicitis with perforation causing bacterial The presence of abdominal distension and abnor- peritonitis and presenting as an acute abdominal mality of meconium evacuation since the day of birth emergency in infants,' neonates2'3'4 and even premature and involvement of the appendix in meconium babies5'6 has been well documented. However, was a towards the only peritonitis strong pointer http://pmj.bmj.com/ one case of prenatal appendicular perforation result- probability of antenatal perforation" as the cause of ing in meconium peritonitis7 has been previously this child's illness. Ileocaecal resection was needed in reported. our case because of the necessity for terminal ileal The usual obstructive appendicitis is rare in neo- resection and extensive adhesions around this region nates as the base of the appendix has a conical caused by meconium peritonitis. Mucoviscidosis configuration which makes obstruction of the lumen could be ruled out in view of normal bowel habits unlikely and before the differential growth of caecum postoperatively in the present case. on September 23, 2021 by guest.

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foration: A case report. J Pediatr Surg 1986, 21: 73-74. 10. Raffensperger, J.G. Meconium ileus, meconium periton- 8. Condon,R.E. Appendicitis. In: Sabiston, D.C. (ed) itis and meconium plug syndrome. In: Raffensper- Davis Christopher Textbook ofSurgery, W.B. Saunders, ger, J.G. (ed) Swenson's Pediatric Surgery. Appleton- Philadelphia, 1981, pp. 1048-1064. Century-Crofts, New York, 1980, pp. 489-494. 9. Lister, J. & Rickham, P.P. Necrotizing enterocolitis: bac- 11. Cerise, E.J. & Whitehead, W. Meconium peritonitis. Am terial and meconium peritonitis. In: Rickham, P.P. & Surg 1969, 35: 389-392. Johnston, J.H. (eds) Neonatal Surgery. Butterworths, London, 1978, pp. 411-428. Protected by copyright. http://pmj.bmj.com/ on September 23, 2021 by guest.